Failure to Provide Baseline Care Plan and Medication List Upon Admission
Penalty
Summary
The facility failed to provide a resident and/or their responsible party with a copy of the baseline care plan and a list of admission medications within 48 hours of admission, as required. The deficiency was identified during a complaint survey involving a resident admitted with a nondisplaced fracture of the lateral condyle of the left humerus and a cast on the left arm. The resident was their own responsible party and had requested communication multiple times without receiving a response. A review of the resident's medical record showed that while the baseline care plan was initiated and reviewed with the resident, there was no documentation that copies of the baseline care plan and medication list were given to the resident or responsible party. The section of the record intended to confirm this action was left blank. During an interview, the LPN/unit manager responsible for the process could not recall if the documents were provided and confirmed there was no evidence of their delivery.